basic resuscitation guideline who

8/7/2019 Basic Resuscitation Guideline Who

1/38


2/38

WHO/RHT/MSM/98.1

Basic newborn resuscitation:

A practical guide


3/38

CONTENTS

pagePREFACE ....................................................................................................................................... 1

EXECUTIVE SUMMARY............................................................................................................. 2

INTRODUCTION ......................................................................................................................... 4

1 GUIDELINES FOR BASIC NEWBORN RESUSCITATION ....................................... 5Anticipate........................................................................................................................... 5Prepare for birth................................................................................................................ 5Immediate care at birth.................................................................................................... 6Assess breathing ............................................................................................................... 6Resuscitate - act quickly and correctly........................................................................... 6Care after successful resuscitation ................................................................................. 9

2 TECHNICAL BASIS....................................................................................................... 10Birth asphyxia ................................................................................................................. 10Management of the newborn with birth asphyxia..................................................... 10Practices that are not beneficial .................................................................................... 14Prevention of infection................................................................................................... 15Clamping and cutting the cord..................................................................................... 15

3 EQUIPMENT AND SUPPLIES..................................................................................... 16For ventilation ................................................................................................................. 16For suction ....................................................................................................................... 17

To prevent heat loss........................................................................................................ 17Clock................................................................................................................................. 18Cleaning and decontamination of equipment............................................................ 18

4 DOCUMENTING RESUSCITATION.......................................................................... 19Records............................................................................................................................. 19ICD codes......................................................................................................................... 20

5 SPECIAL CONDITIONS ............................................................................................... 21When to start resuscitating............................................................................................ 21When to stop resuscitating............................................................................................ 23Failed resuscitation......................................................................................................... 23Other special conditions ................................................................................................ 23

6 SPECIAL CIRCUMSTANCES ...................................................................................... 25Mouth to mouth-and-nose breathing .......................................................................... 25Mouth-to-mask ventilation............................................................................................ 25

7 OPERATIONAL GUIDELINES .................................................................................... 27Implementation of resuscitation in practice................................................................ 27

8 GLOSSARY...................................................................................................................... 29

9 REFERENCES ............................................................................................................31


4/38

Basic newborn resuscitation: A practical guide

PREFACE

What is this document about?

This document describes a simple method for resuscitating newborn infants, even whereresources are limited. It is believed that this basic method of resuscitation - if carried outcorrectly - can revive more than three-quarters of newborns who do not breathe at birth.The method is especially suitable where only one birth attendant is present at the birthand has to divide her/his attention between the mother and the newborn. This documentdescribes the procedures, that should be carried out, gives the reasons for selectingparticular actions and also gives suggestions on how to operationalize the programme.

Who is this document for?

This document is written for health professionals who are responsible for implementingeffective newborn resuscitation in health facilities and for national managers responsiblefor maternal and newborn health.

How should this document be used?

This document is intended as a basis for developing national and local policies, standardsand guidelines to be followed by all health professionals who may be involved inresuscitating newborns. It should be regarded not as a rigid protocol but as an effectiveand safe method that is based on experience, current evidence and research. Thedocument can be used for developing training materials for basic newborn resuscitation.


5/38

2 Basic newborn resuscitation:

EXECUTIVE SUMMARY

A survey of health care institutions in 16 developed and developing countries showedthat there was often no basic equipment for resuscitating newborns, or that it was in poor

condition and health personnel were not properly trained in newborn resuscitation.

According to WHO estimates, around 3% of the 120 million babies born each year indeveloping countries develop birth asphyxia and require resuscitation. It is estimatedthat some 900,000 of these newborns die as the result of asphyxia.

A single intervention - resuscitation - deals with the problem of birth asphyxia as itoccurs.

The need for resuscitation should always be anticipated. Thus, every birth attendant

should be skilled in newborn resuscitation, (including anticipation, preparation, timelyrecognition and quick and correct action) and should have the necessary equipment andsupplies - clean and functioning - to be able to respond quickly and correctly whenneeded.

Every newborn should be first dried, wrapped in a dry cloth, and assessed forcrying/breathing. If the newborn is not breathing, the airway should be opened bypositioning the head correctly, the mouth and nose should be quickly suctioned and thelungs ventilated with the self-inflating bag via a soft fitted face mask. The effect ofventilation is assessed by observing the chest rise.

Minimum equipment and supplies for newborn resuscitation include a heat source(preferably a radiant heater) to prevent heat loss (if this is not available, prewarmedtowels and an extra blanket can be used to cover the newborn), a mucus extractor forsuctioning, a self-inflating bag of newborn size, two masks (for normal and smallnewborns) for ventilation, and a clock to assess time correctly.

Adequate ventilation is more important than additional oxygen; quick action with thebag and mask is more important than intubation. Therefore resuscitation can and shouldbe initiated virtually anywhere, including those places where oxygen is not readilyavailable. The choice of device for ventilation is not as important as how effectively it is

used. The most common causes of failed resuscitation are failure to recognize theproblem promptly, not reacting quickly enough and not ventilating effectively. Correcttechnique and assessment of the effectiveness of ventilation are critical.

Advanced procedures (chest compression, intubation, administration of oxygen, use ofdrugs) are needed only in a small proportion of cases. These procedures have strictindications and are beneficial only in specific circumstances and if carried out by anexperienced person.

In reality, even the simplest equipment is frequently not available and skilled healthworkers are lacking. In many places only one birth attendant is normally present at the

birth, dividing her attention between the mother and the newborn. In such circumstances,


6/38

A practical guide

the birth attendant can properly carry out only a certain number of procedures in thelimited amount of time available for resuscitation.Basic resuscitation will not help all newborns but, done correctly, it will help most, evenwhere only few resources and simple training are available.

The probability of sequelae is low if a newborn infant is resuscitated promptly andcorrectly and starts breathing spontaneously within 20 minutes. Whether resuscitationsucceeds or fails will depend on anticipation, preparation, skills and functioningequipment, timely initiation and correct procedures. Delayed or ineffective action makesresuscitation more difficult and increases the risk of brain damage.

To provide basic newborn resuscitation for all newborns who need it, each healthinstitution needs to introduce it as a practice, to maintain the skills of the staff and toensure that functioning equipment and supplies are always available. At national level,legislation, standards, training courses and training material will help health workers to

carry out the task.


7/38


INTRODUCTION

A survey of 127 institutions in 16 developed and developing countries has shown that

there was often no basic resuscitation equipment, or that it was in poor condition, andthat health personnel were not properly trained in newborn resuscitation.i A study ineight African countries showed that, even in central hospitals, resuscitation measureswere inappropriate for a significant proportion of newborns with asphyxia. ii

In this document birth asphyxia is defined simply as the

failure to initiate and sustain breathing at birth

According to WHO estimates, around 3% of approximately 120 million infants born everyyear in developing countries develop birth asphyxia requiring resuscitation. It isestimated that some 900,000 of these newborns die each year. iii,iv

The incidence of birth asphyxia is higher in developing countries than in developedv,vibecause of a higher prevalence of risk factors, namely: women are in poor health whenthey become pregnant; the incidence of pregnancy and delivery complications in thesewomen is high; care during labour and delivery is often inadequate or nonexistent; andabout 10% of infants are estimated to be born preterm. Thus, resuscitation of newborns ismore often needed in developing countries than in developed. However, most newbornsdo not at present receive adequate care because most birth attendants do not have the

necessary knowledge, skills and equipment to help them. Some traditional practices arenot only ineffective in reviving depressed newborns but are also harmful to them.

The common worry of health professionals and parents is the permanent brain damagethat birth asphyxia can cause and the common aim is to reduce the number of newbornsaffected. Improving women's health and health care will reduce the risk factors anddecrease the number of newborns needing resuscitation. However, as there is no singlecause of poor maternal health there is no single intervention that will improve it.Reducing the incidence of birth asphyxia will therefore take time.

Nevertheless, there is one single intervention for dealing with asphyxia when itoccurs - resuscitation. The need for resuscitation can sometimes be predicted though veryoften it cannot. Therefore every birth attendant must be both skilled and equipped toresuscitate newborns who do not start breathing spontaneously. The approach should befeasible even where resources are limited.

Because of the lack of reliable evidence there are still many unanswered questionsconcerning newborn resuscitation. More research is needed to find the best possiblemethod of resuscitation. However, we already know enough to help most infants whohave trouble starting to breathe.

This document does not deal in detail with the physiology and pathophysiology ofbreathing at birth. It focuses mainly on one method of resuscitation, gives evidence for


8/38

A practical guide

the effectiveness of this method, raises ethical concerns about it, and describes specialsituations when the method might need to be modified. The recommendations in thisdocument are based on scientific evidence, where available, and on experience from bothdeveloping and developed countries.vii,viii,ix,x,xi The information provided is intended to

facilitate the preparation of national and local standards and guidelines.


9/38


1 GUIDELINES FOR BASIC NEWBORN RESUSCITATION

Effective basic resuscitation will revive more than three-quarters of newborns with birthasphyxia. It will not delay deaths or increase the number of disabled children if the steps

below are followed.

AnticipateBe prepared for every birth by having the skill to resuscitate and by knowing theinstitution's policy on resuscitation. Review the risk factors for birth asphyxia (see Table1, page 11). Get help if necessary and if possible. Clearly decide on the responsibilities ofeach health care provider during resuscitation.

Remember that the mother is also at greater risk of complications. Her greatest immediate

danger is bleeding.

Prepare for birthMake sure that the following are available for the newborn: two clean (warm) towels forthermal protection (drying and wrapping/covering the newborn to prevent heat loss)and a draught-free delivery room with a temperature of at least 25 C.

Figure 1: Self inflating bag and face mask

For cleanliness, use water, soap, gloves, a clean surface for the newborn and a cleandelivery kit for cord care. For resuscitation, a self-inflating bag (newborn size) (Figure 1),two infant masks (for normal and small newborn), a suction device (mucus extractor), aradiant heater (if available), warm towels, a blanket and a clock are needed.

Always have an additional set of equipment in reserve for multiple births or in case offailure of the first set.


10/38

A practical guide

Immediate care at birthWash hands with water and soap when preparing for the birth. Use gloves. Deliver thenewborn. Remember the time, hour and minute of the birth.

Note that the newborn should be wrapped during theassessment, suction and ventilation to be protected fromheat loss. Figures in this document show the newbornnaked to make the important details clear. Other detailssuch as the cord are omitted for the sake of simplicity.Lie the newborn on the mother's abdomen or other warm surface. Immediately dry thenewborn with a clean (warm) towel. Remove the wet towel and wrap/cover the newborn,except for the face and upper chest, with a second dry towel. While drying make sure thatthe head is in a neutral position, neither too flexed nor too extended.

Assess breathingIf the newborn is crying, breathing is normal and no resuscitation is needed. Providenormal care. If there is no cry, assess breathing: if the chest is rising symmetrically withfrequency >30/minute, no immediate action is needed. If the newborn is not breathing orgasping, immediately start resuscitation. Occasional gasps are not considered breathing.If necessary, tie and cut the cord.

Resuscitate - act quickly and correctlyInform the mother - explain to her quickly what the problem is and what you are going todo. Tell her to watch for vaginal bleeding - if she starts bleeding she should tell you.

Figure2: Correct position of the head for ventilation


11/38


Open the airwayPosition the newborn by moving it from the mother's abdomen to a dry, clean and, ifpossible, warm surface next to her. Put the baby on its back. Position the head so that it isslightly extended (Figure 2). A folded piece of cloth under the shoulders may help

accomplish this. Clear the airway by suctioning first the mouth and then the nose (Figure3). Be especially thorough if there is blood or meconium in the baby's mouth and/or nose.The newborn may start breathing because suctioning provides additional stimulation. Ifso, no immediate further action is needed. If there is still no breathing, start ventilating.

Figure 3: Suctioning the mouth and nose

VentilateSelect the appropriate mask (size 1 for a normal weight newborn, size 0 for a smallnewborn). Reposition the newborn - make sure that the neck is slightly extended. Placethe mask on the newborn's face, so that it covers the chin, mouth and nose (Figure 4).Form a seal between the mask and the infant's face. Squeeze the bag with two fingers onlyor with the whole hand, depending on the size of the bag and manufacturer s instructions.Check the seal by ventilating two or three times and observing for the rise of the chest(Figure 5).

If the chest is not rising, the most probable obstacles areinappropriate head position, poor seal between the

mask and the face, insufficient ventilation pressure ormucus, blood or meconium in the airway. Thecorrective steps are repositioning of the newborn's head,repositioning of the face mask, increased ventilationpressure by pressing the bag with the whole hand;exactly how much to press will depend on the size ofthe bag and further suctioning of the upper airway. Thefirst ventilations require higher inflation pressure thanlater ventilation.

Figure 4: Fitting the face mask


12/38

A practical guide

Figure 5: Ventilation with bag and mask

Once a seal is ensured and chest movement is present, ventilate the newborn with afrequency of around 40 breaths per minute, the range being 30-60 (better more than less).After effectively ventilating for about 1 minute, stop briefly but do not remove the maskand bag and look for spontaneous breathing. If there is none or it is weak, continueventilating until spontaneous cry/breathing begins. Observe the chest for an easy riseand fall. Hold the head in the correct position to keep the airway open during ventilationand keep a tight seal between the mask and the face. Continue ventilating. If the chest isrising, ventilation pressure is most probably adequate.

If the newborn starts crying, stop ventilating but do not leave the newborn. Observe

breathing when it stops crying; if breathing is normal - 30-60/min - and there is no chestor costal indrawing and no grunting for one minute, no further resuscitation is needed.Tie the cord and cut it (if not done earlier). Put the newborn skin-to-skin on the mother'schest to prevent heat loss.

If breathing is slow (frequency of breathing is


13/38


Resuscitation practices that are not effective or are harmfulThese include:

- routine aspiration (suction) of the baby's mouth and nose as soon as the head is

born, or later when the amniotic fluid has been clear;- routine aspiration (suction) of the baby's stomach at birth;- stimulation of the newborn by slapping or by flicking the soles of its feet;- postural drainage, and slapping the back;- squeezing the chest to remove secretions from the airway;- routine giving of sodium bicarbonate to newborns who are not breathing;- intubation by an unskilled person.

Care after successful resuscitationDo not separate the mother and the newborn. Leave the newborn skin-to-skin with themother.

After taking care of the mother's needs, examine the newborn. Measure the newborn'sbody temperature, count breaths, observe for indrawing and grunting, and observe formalformations, birth injury or other danger signs. (See reference 12.)

Encourage breast-feeding within one hour of birth. The newborn that needs resuscitationis at higher risk of developing hypoglycaemia. Observe suckling - good suckling is a signof good recovery.

If the temperature is


14/38

A practical guide

2 TECHNICAL BASIS

Birth asphyxiaSeveral important things happen to a baby at birth to enable it to make the transition to

extrauterine life. Changes take place in the lungs to allow breathing, and changes in theheart and circulatory system switch off circulation through the placenta and redirect itthrough the lungs.

In most babies these changes occur smoothly; the babies start breathing as soon as theyare delivered, within a minute of birth at the latest, and they adapt within just a fewminutes. All they need is a clean and warm welcome, and vigilant observationxiii,xiv - tobe born in a warm room, to be dried immediately, to be observed for breathing, and to begiven to the mother for warmth and breast-feeding. The newborn's cry at birth - one of themost eagerly anticipated events - is commonly considered a cry of health. Studies have

shown that a vigorous cry is an important indicator of the health of the newborn.xv

Othersigns of good health at birth are pink skin, good muscular tonus and good reactions. Theheart rate in a healthy baby is always normal, i.e. above 100/minute. For most infantsnothing more is needed and nothing further is recommended. The mother is the bestsource of warmth, affection, food and protection from infection, and she is the bestobserver of the newborn in the days to come.

In a small proportion of newborns (3-5%) the changes do not occur smoothly and thenewborns do not start breathing immediately and spontaneously.3,xvi They have what iscalled birth asphyxia and they need assistance to initiate breathing. In other words theyneed resuscitation.

In this document birth asphyxia is defined simply as the failure to initiate and sustainbreathing at birth, since there is no agreement among obstetricians and neonatologists ona more precise definition.xvii,xviii

In most circumstances, it is not possible to tell with certainty how severe birth asphyxia isby clinical methods.16 The concept of primary and secondary apnoea is often used indescribing what goes wrong but it is not particularly useful in determining the severity ofasphyxia and guiding resuscitation. If the newborn that is not breathing is also limp,asphyxia is probably severe. However, resuscitation can always be started in the same

way.

Management of the newborn with birth asphyxia

Basic resuscitationRegardless of the cause of birth asphyxia and how severe it is, the action - at least theinitial steps - will be the same: ventilation. The main aim is to ensure oxygenation and toinitiate spontaneous breathing. Effective ventilation must be established before any othersteps are taken. Too often other more complicated procedures are initiated first. This canbe harmful to the newborn. Anticipation, adequate preparation, timely recognition andquick and correct action are critical for the success of resuscitation.16


15/38


Anticipation of resuscitation

Resuscitation must be anticipated at every birth. Every birth attendant should be

prepared and able to resuscitate since, if it is necessary, resuscitation should beinitiated without delay.Some maternal and fetal conditions that are risk factors for birth asphyxia are listed inTable 1. Good management of pregnancy and labour/delivery complications is the bestmeans of preventing birth asphyxia. Frequent auscultation of fetal heartbeat, especiallyduring the second stage of labour, may help to diagnose fetal distress and to predict thebirth of a baby that will need resuscitation.

Adequate preparationRisk factors are poor predictors of birth

asphyxia. Up to half of newborns who requireresuscitation have no identifiable risk factorsbefore birth.16 Therefore it is not enough to beprepared only in cases where one or more riskfactors are present.

Every birth attendant must be trained inresuscitation and must have resuscitationequipment and supplies in perfect condition(see page 16 for equipment and supplies).When no equipment is available, mouth tomouth-and-nose breathing should be done.When a newborn is expected to have severeasphyxia, a second person should be availableto assist at the birth.

Assessment and timely recognition of theproblemIf the newborn does not cry or breathe at all,or is gasping within 30 seconds of birth, and

after being dried, the essential steps ofresuscitation should be taken immediately.

The baby's cry is the most obvious sign that there is adequate ventilation after the birth. Ina crying newborn the heart rate is normal. Breathing immediately after birth may beirregular but is usually still sufficient for adequate ventilation. However, gasping(occasional breaths with long pauses in between) is not sufficient.

Taking an Apgar score is not a prerequisite for resuscitation. The need for resuscitationmust be recognized before the end of the first minute of life which is when the first Apgarscore is taken. The most important indicator that resuscitation is needed is failure tobreathe after birth so, if the baby does not breathe, resuscitation must be startedimmediately.

Some maternal and fetal risk factors for birth

asphyxia are:

- maternal illnesses such as sexuallytransmitted diseases

- malaria- eclampsia (including the treatment)- bleeding before or during labour- fever during labour- maternal sedation, analgesia oranaesthesia

- prolonged rupture of membranes- breech or other abnormal presentation

- prolonged labour- difficult or traumatic delivery- prolapsed cord- meconium-stained amniotic fluid- preterm birth- post-term birth- multiple birth- congenital anomaly.


16/38

A practical guide

Apgar scoring has been used as a systematic tool to assess and document the clinicalstatus of the newborn at birth, or more precisely at 1 and 5 minutes of life. The newborn isexamined for five signs: breathing, heart rate, muscle tone, reflex irritability and colour(see Table 2). Determining the Apgar score correctly requires good training. The score

depends not only on the severity of birth asphyxia but also on other factors such as drugsgiven to the mother, anaesthetics, fetal infection, fetal anomalies and prematurity.

Quick and correct action

The important steps in resuscitation are prevention of heat loss, opening the airway andpositive pressure ventilation that starts within the first minute of life.

Prevention of heat loss is critical. Methods should include those that prevent the loss ofheat by evaporation, radiation, conduction and convection. Each newborn should bedried first and then covered with a dry towel. The surface on which it is placed shouldalways be warm as well as flat, firm and clean.xixDrying provides sufficient stimulationof breathing in mildly depressed newborns and no further stimulation is appropriate.

Resuscitation should be started immediately. There is no evidence that hypothermiahelps to initiate breathing or reduces damage due to birth asphyxia.13,14

To open the airway in a baby that is not breathing, the newborn must be positioned on itsback, with the neck slightly extended (Figure 2, page 7). The upper airway (the mouthand nose) should be suctioned to remove fluid if stained with blood or meconium (Figure3, page 8). Suctioning must be thorough but gentle and quick. It may create additionalstimulation for breathing.

When the amniotic fluid is stained with meconium, there is no evidence that suctioningthe nostrils and oropharynx before the chest is delivered and before umbilical circulationis interrupted has any important effect on the incidence of severe meconium aspirationsyndrome.13 Nevertheless it is practised widely. However, women take differentpositions for delivery and suctioning before the whole baby is delivered may not bewithout risk in some positions.

ScoreSign

0 1 2

Heart rate Absent Slow (100beats/min

Breathing Absent Slow, irregular Good, crying

Muscle tone Limp Some flexion Active motion

Reflexirritability

Noresponse

Grimace Cough,sneeze

Colour Blue orpale

Pink body withblueextremities

Completelypink

Table 2: Apgar scoring


17/38


Positive pressure ventilation is the most important aspect of newborn resuscitation forensuring adequate ventilation of the lungs, oxygenation of vital organs such as heart andbrain, and initiation of spontaneous breathing. Ventilation can almost always be initiatedusing a bag and mask (it is rarely necessary to intubate) and room air.11,15,xx To open the

lungs the ventilation pressure required is 30-40 cm of water; later around 20 cm issufficient for ventilating healthy lungs. Sometimes the initial (opening) pressure could beas high as 50-70 cm of water. Approximately 40 breaths per minute are required.16 Only asoft mask provides a good seal with the newborn's face to in achieve this pressure.xxiAdequacy of ventilation is assessed by observing the chest movements (Figure 5, page 9).The best indication of adequate pressure is the chest rising and falling easily withventilation. If two skilled birth attendants are present, the one who is not ventilating canauscultate the lungs for breathing sounds and heart rate.

The above are the essential first steps of any resuscitation. They will, according toexperience, establish spontaneous breathing in more than three-quarters of newborns

with birth asphyxia.xxii

Advanced resuscitationA small proportion of infants fail to respond to ventilation with the bag and mask. Thishappens infrequently but, when it does, additional decisions must be made and actionstaken. Advanced procedures can be introduced in a health care institution if the followingcriteria are met: (a) trained staff with the necessary equipment and supplies are available;(b) at least two skilled persons are available to carry out the resuscitation; (c) there aresufficient deliveries for the skill to be maintained; and (d) the institution has the capacity

to care for or to transfer newborns who suffer severe birth asphyxia since they areexpected to have problems after being resuscitated. Guidelines and training materials onadvanced newborn resuscitation are available from universities and professionalorganizations. Below is a brief outline of the procedures.

Endotracheal intubation

This has been shown to provide more effective ventilation in severely depressed/illnewborns. It is more convenient for prolonged resuscitation but is also a morecomplicated procedure that requires good training. Endotracheal intubation is neededonly rarely and can be dangerous if performed by untrained staff. Potential hazardsinclude cardiac arrhythmias, laryngospasms and pulmonary artery vasospasm13,14Usually only newborns that are severely ill will require endotracheal intubation.

Tracheal suction by a skilled resuscitator has been shown to reduce morbidity amongdepressed infants born with meconium in the pharynx.13,14 However, it requires a highlyexperienced person to do it without causing damage. Despite its potential benefit,tracheal suction is not recommended unless the resuscitator is very skilled, because of thesevere hazards associated with it (hypoxia, bradycardia).14

OxygenAdditional oxygen is not necessary for basic resuscitation 10,xxiii,xxiv although it has beenconsidered so by some practitioners. Oxygen is not available at all places and at all times.


18/38

A practical guide

It is also expensive.xxv Moreover, new evidence from a controlled trial shows that mostnewborns can be successfully resuscitated without additional oxygen.11,24 Research alsosuggests that high oxygen concentration may not be beneficial in most circumstances.xxviHowever, when the newborn's colour does not improve despite effective ventilation,

oxygen should be given if available. An increased concentration of oxygen is needed forsevere lung problems such as meconium aspiration and immature lung, or when the babydoes not become pink despite adequate ventilation.

Chest compressionsChest compressions are not recommended for basic newborn resuscitation. There is noneed to assess the heartbeat before starting ventilation. Slow heartbeat is usually causedby lack of oxygen, and in most newborns the heart rate will improve as soon as effectiveventilation is established. Effective ventilation should be established before chestcompressions are started.

It has been shown that it is more difficult to assess the heart rate reliably in newborns thanin older children, especially by feeling the beat (pulse) through the chest wall or over bigarteries. Therefore a person without experience is highly likely to make a mistake inassessing the heart rate in a newborn.xxvii Assessing the heart rate without the necessaryskill and equipment is a waste of time, and a wrongly assessed pulse may lead to wrongdecisions.

However, in newborns with persistent bradycardia (heart rate


19/38


stimulating the anus, using onion juice, cooking the placenta and milking the cord are afew examples of ineffective and harmful practices still used.7

Modern practices

Not all modern practices are beneficial either. Some derive from traditional practices,while others were introduced in good faith by health professionals but without goodevidence that they would be beneficial.

Tactile stimulation

Various methods have been used to stimulate newborns that do not breathe immediatelyafter birth. Holding the newborn's head down by holding the baby by the legs has beenproved dangerous. Slapping and flicking of the soles, although effective in the experienceof many, may initiate breathing only in mildly depressed newborns. Thorough drying

provides enough stimulus for breathing, and also protects against hypothermia. Since it isdifficult to predict the severity of birth asphyxia by clinical methods alone, additionalstimulation is a waste of time and is not recommended. Instead, assisted ventilationshould be started immediately.

Routine aspiration of upper airwayThere is no evidence that routine aspiration of the newborn's mouth and nose as soon asthe head is born or later is of any benefit if the amniotic fluid has been clear. 14,xxix Theprocedure is therefore unnecessary in newborns who start crying or breathing

immediately after birth. Routine suctioning is associated with hazards such as cardiacarrythmia.13,14

Routine gastric suctioningThere is also no justification for routine gastric suctioning at birth.14

Postural drainagePostural drainage and slapping the back are not effective and should not be practised.Squeezing the chest to remove secretions from the airway is also dangerous as it may

cause fracture, lung injury, respiratory distress and death.

Sodium bicarbonateSodium bicarbonate is not recommended in the immediate postnatal period if there is nodocumented metabolic acidosis. It should therefore not be given routinely to newborns whoare not breathing.14

Prevention of infection

Although universal precautions to prevent infection should be part of routinelabour/delivery/newborn care, health providers should be especially cautious duringresuscitation to protect the newborn and themselves from agents such as the human


20/38

A practical guide

immunodeficiency virus (HIV). Precautions to prevent the transmission of HIV and otherinfections include washing of hands, use of gloves, careful suctioning if using a mucusextractor operated by mouth, careful cleaning and disinfection of equipment and supplies,and correct disposal of secretions. In an emergency situation such as resuscitation it is

easy to forget such precautions, so they need to be emphasized during training.

Clamping and cutting the cordIt is not necessary to clamp and cut the cord before starting resuscitation. Resuscitationcan start while the newborn is still on the cord, unless clamping and cutting can be donequickly, or the cord is too short to put the newborn safely on a dry, firm and flat surfacethat is easily accessible for resuscitation, or in case of birth by caesarean section. No timeshould be wasted to move the newborn to a special place for resuscitation. The mother'sbed is usually a warm and suitable place for resuscitation unless it is too narrow.


21/38


3 EQUIPMENT AND SUPPLIES

Basic newborn resuscitation requires a bag and a mask for ventilation, a mucus extractorfor suctioning, a source of warmth for thermal protection, and a clock. It is important to

choose quality equipment that will not fail when it is most needed. A resuscitation trolleyis useful but is not absolutely necessary. In the operating theatre where caesarean sectionsare performed, a corner that is protected from draught and can be kept warm should beprepared for the immediate care of the newborn, including resuscitation when needed.

An institution should have at least two sets of equipment in case of multiple births, or forother births occurring at the same time, or in case one set does not function.

For ventilation

A self-inflating bag of newborn/infant size is recommended for basic newbornresuscitation (Figure 1, page 6). The bag refills because of its elasticity and does not needcompressed gas to work correctly. It can be used simply to deliver air (which contains21% oxygen).

The volume of the bag should be 250-400 ml. Regardless of the mechanism used for thepatient valve, the bag should generate a pressure of at least 35 cm of water. A self-limitingpressure valve is not required when a small bag is used without gas under pressure. Bagsshould be easy to assemble and disassemble and easy to clean.

Mask

A good mask is critical for a good seal with the face and for effective positive pressureventilation. Research and experience show that a soft circular mask that adapts its shapeto the contours of the newborn's face provides a tight seal with the face and leaks less thanother types of masks.21 At least two sizes of mask for normal and small newborns areneeded per bag.

Bags and masks can be made of different materials: rubber, plastic or silicone. Thematerial should be able to undergo commonly available methods of disinfection andsterilization (boiling, autoclaving, disinfection) to prevent cross-infection. The mask

should preferably be made of one piece for easy cleaning. Material that can standextremes of climate, according to the country concerned, should be chosen.

Various mechanisms are used for one-way patient valves. The most important criteria forselection of the bag are delivery of the required ventilation pressure and frequency andthe ability to regulate the pressure.


22/38

A practical guide

For suctionIt is preferable to use mechanical equipment togenerate negative pressure for suction. Negativepressure should not exceed 100 mmHg (130 cm

water). The catheter must be wide enough toremove meconium effectively. The recommendedsize for the catheter is 12F and it should have sideholes at the tip.28 A single size can be used for allnewborns.

If mechanical equipment is not available,negative pressure can be generated by theresuscitator. The mucus extractor, also called theDeLee suction device, is an independent suctionapparatus. It has a catheter leading to a smallcollection reservoir and a second tube from thereservoir to a mouthpiece placed in the operator'smouth to generate suction (Figure 6). The trapmust be big enough (20 ml) to prevent suction offluids into the resuscitator's mouth.

With the widespread adoption of universal precautions, this type of mucus extractor isnot recommended where alternatives exist. A modified version has a filter that preventsaspiration of the contents of the container. Disposable mucus extractors and catheters arerecommended. However, if they are reusable, the recommendations for cleaning and

decontamination should be followed (see page 20).

A bulb is not recommended for suctioning the mouth and nose unless special cleaningfacilities are available because it is difficult to clean. A dirty bulb can become a source ofcross-infection.

The least preferred method of clearing the airway is wiping the mouth with a finger andpiece of cloth or other absorbent material. There is no evidence that this method iseffective in clearing the airway and it may damage the mouth mucosa.

To prevent heat lossBesides drying and wrapping the newborn the best way to provide extra warmth forresuscitation is to use a radiant heater. However, this will provide sufficient warmth onlyif it is preheated so that the surface is warm, if it is the correct distance from the infant andif the room is warm. The heater should be selected and used with caution. Focusingwarming bulbs are a less expensive alternative. The source of warmth should preferablybe mobile so that it can be moved near the place of birth. Instructions about the distancebetween the source of warmth and the newborn should be carefully followed to avoidoverheating, burns or hypothermia. Burns have been described in newborns beingresuscitated under radiant heaters despite precautions.

Figure 6: Mucus extractor


23/38


The use of silver swaddlers and bubble wraps for thermal protection of newborns duringresuscitation has not been systematically evaluated and there is no evidence forrecommending them. If a swaddler is used, the baby should be dried before beingwrapped in it.

ClockIn emergency situations, such as at the birth of a newborn with asphyxia, people often donot have good sense of time. Good practice requires recording the time of birth and, asresuscitation takes place, checking the time often in order to make decisions aboutmodifying or discontinuing it. A large wall-clock with hands indicating both minutes andseconds is therefore needed and should be easily visible in the delivery room.

Cleaning and decontamination of equipment

Equipment and supplies must be cleaned and disinfected after each use. Manufacturersprovide specific instructions for cleaning, disinfection and/or sterilization of equipmentand these should be followed carefully.

Where instructions are not available, general recommendations are as follows.

Bag and mask

The mask and the patient valve should both be disinfected after each use since they areexposed to the newborn and to expiratory gases. The bag and the inlet valve should be

disinfected after use with an infected newborn, and otherwise occasionally.

The valve and the mask must first be disassembled, inspected for cracks and tears,washed with water and detergent and rinsed. Selection of the decontamination methodwill depend on the material. Silicone and rubber bags and patient valves can be boiled for10 minutes, autoclaved at 136 C or disinfected by soaking in a disinfectant. Dilution ofdisinfectant and exposure time should be in accordance with the instructions of themanufacturer. All parts must be rinsed with clean water after chemical disinfection andair-dried before assembling.

After re-assembling, the bag must be tested to check that it works correctly. Mostmanufacturers give step-by-step instructions for this procedure. If instructions are notavailable, use the following test: block the valve outlet by making an airtight seal with thepalm of the hand. Squeeze the bag and feel the pressure against the hand. Observe if thebag reinflates when the seal is released. If the bag is not functioning correctly, it should berepaired before use. Repeat the test with the mask attached to the bag.

Suction catheter, mucus extractor

Disposable suction catheters and mucus extractors should be disposed of correctly.Reusable ones should be disassembled, washed with water and detergent, boiled and

disinfected or sterilized after each use, according to the material they are made of.Washing the catheter requires a syringe to rinse the tube.


24/38

A practical guide

4 DOCUMENTING RESUSCITATION

RecordsAll health care institutions should keeprecords/logbooks with basic information on everybirth. This basic information should include someimportant details about the condition of the newbornat birth and about resuscitation if this is done. Theinformation should also be recorded in home-basedrecords.

Documenting conditions and procedures at birth isimportant for several reasons. There are, for instance,

medico-legal implications. If any problems arise laterthorough documentation can help in understandingthe circumstances at the birth. Case reviews alsoprovide a basis for further education and theimprovement of practice.

Details of resuscitation to be recorded are:- identification of the newborn;- condition at birth;- procedures necessary to initiate breathing;- time from birth to initiation of spontaneous

breathing;- clinical observations during and after

resuscitation;- outcome of resuscitation;- in case of failed resuscitation, possible reasons

for failure;- names of health care providers involved.

An example of a record of newborn resuscitation is shown in Table 3. This is the record ofthe resuscitation only and does not replace the record of delivery/birth.

Newborn name: ..................................................Date of birth: ...............................Time of birth:Condition at birth: .........

Immediate cry/breathingDelayed cry/breathing

Resuscitation not attempted.Explain why not: ................................................

Resuscitation initiated.* .................Describe procedures:

..........................................................................*When did spontaneous breathing

begin? ...............................................................................................................................

* .....For how long (minutes) wasventilation needed? ...........................................

*How was the condition (breathing,body temperature, suckling) of the newborn 30-60min after resuscitation? .....................................

.............................................................*If no spontaneous breathing, when

did ventilation stop? ..........................................How would you describe the outcome?

a Liveborn infant, resuscitation successful.b Liveborn infant, resuscitation not successful,

the newborn died.c Stillborn, resuscitation not successful.d Stillborn, resuscitation not attempted.

Consider ICD-10 codes P21 for options a, b, andc if no other condition.


25/38


ICD codes

Every hospital has a system for coding conditions. WHO recommends use of theInternational Classification of Diseases, 10th edition (ICD-10). ICD-10 provides codes for

conditions, not procedures.

There is no ICD-10 code that matches exactly the definition of birth asphyxia used in thisdocument: a preterm newborn does not necessarily suffer from birth asphyxia as definedin ICD-10 but has difficulty in starting to breathe because of immaturity while a newbornwith intrauterine infection will have the same problem because of the disease. However,for all these circumstances, P21 - Birth asphyxia is the most appropriate code. The subcodescan be used for different severities of birth asphyxia.


26/38

A practical guide

5 SPECIAL CONDITIONS

When to start resuscitatingThere is a lot of concern that simple resuscitation only delays death or results in a severely

disabled infant, thus draining scarce resources, especially when the newborn has a severemalformation, is extremely preterm or has extremely low birth weight, or is anapparently stillborn fetus.

There are no clear guidelines on when to start and when to stop newborn resuscitation.The most frequently asked questions are whether the baby will be damaged if it isresuscitated and survives, and whether it will be a burden for the family and the society.Too often the decision not to start resuscitating and the decision to terminate are left tothe person caring for the newborn.

Instead of leaving these difficult decisions to individuals, each health care institutionneeds a clear policy for such cases. The policy can be developed through organizedgroups of lay, medical and legal personnel. These groups should take into considerationseveral important issues:

- Even if resuscitation is not initiated the newborn may not die. Withholding ordelaying resuscitation at birth may result in a poor outcome due to the consequencesof hypoxic/ischaemic encephalopathy and multisystem organ injury. No advancedcare at a later stage can substitute for effective resuscitation at birth and repair thedamage due to delayed or incorrect procedures.

- The concern may not be whether resuscitation will be successful or not but whether,if it is successful, the infant will be severely damaged. The decision to resuscitateinvolves a long-term commitment to the care of the child.13,16,xxx

- A determinant of when to start or to stop resuscitation is the capacity of theinstitution/country for the management and further care of malformed, verypreterm or severely damaged newborns.

- The decision to resuscitate newborns of low gestational age should take intoconsideration the likelihood of survival, the major initial obstacles to survival that the

newborn is likely to encounter outside the womb, and the possible long-termsequelae of prematurity that include chronic lung disease, hearing and visualimpairment, and neurodevelopmental delay. It is important to base decisions onlocal data on survival at different gestational ages.

Whenever a doubt exists a liberal policy of newborn resuscitation is recommended.13,14In individual cases parents must be consulted as soon as possible, and their wishesshould be respected. If it is unclear what to do, it is better to resuscitate since a milddisability or malformation (e.g. cleft lip) will be aggravated by brain damage if thenewborn is not resuscitated properly but nevertheless survives.


27/38


Apparently stillborn fetusIf after delivery the fetus does not breathe and shows no other evidence of life (such asbeating of the heart, pulsation of the umbilical cord, definite movement of voluntarymuscles) or shows signs of maceration, it is considered stillborn. However, in a fresh

stillborn newborn it is difficult to determine how long before birth the death occurredunless the fetal heartbeat has been checked frequently during the second phase of birth.The policy on when to initiate resuscitation will depend on the practice of monitoringfetal well-being. If the fetal heartbeat was heard shortly before birth, resuscitation shouldbegin.

MalformationsIf the newborn has a severe malformation that islethal, resuscitation should not be attempted. Alist of identifiable malformations that areincompatible with life is shown in Table 4

(adapted from reference 30). Thesemalformations have either a lethal outcome, orvegetative survival, or the defect requires majorcorrective surgery. Most can be easily diagnosedat birth. Less severe malformations such as bigomphalocoele can be added to the list if there areno facilities for their correction and care.However, most malformations are not lethal. Ifthe newborn with a malformation is not resuscitated correctly, it may survive with adouble disability - the malformation and brain damage due to prolonged asphyxia.

Abnormalities that also cause serious difficulties for resuscitation, such as diaphragmatichernia, hypoplastic lung, or cardiac defects, are not visible and therefore cannot be easilydiagnosed at birth. They are rare (


28/38

A practical guide

When to stop resuscitatingThe decision of when to stop resuscitation of newborns who fail to show signs of life atbirth is a major dilemma for health professionals and parents.

There is no clear information as to the maximum duration of resuscitation that should berecommended. A newborn that does not start breathing after 20 minutes of adequateventilation has probably suffered severe asphyxia. It will probably require intensive careif it survives. If such care is available, the ventilation could continue for 30 minutes whileadmission to the intensive care unit is being arranged. If such care is not available (i.e. inmost circumstances) ventilation can be discontinued if there is no response (nospontaneous breathing) after 20 minutes of ventilation. A period as short as 10 minuteshas been proposed by some practitioners, but there is no evidence to support such arecommendation.xxxii

Failed resuscitationNot every resuscitation will be successful in reviving the newborn. It is very important toinform parents fully about failed resuscitation, explaining to them in a way they canunderstand the circumstances and probable causes of failure. Details of failedresuscitation must be recorded thoroughly. Death must be reported as required by theauthorities. Disposal of the body should be arranged according to the regulations andparents' wishes. Parents may need counselling to deal with the newborn's death. Thecircumstances of the failed resuscitation must be discussed and analyzed with the staffsoon after the event. Any problems should trigger further investigation and properaction.

Other special conditionsThe recommendations on basic resuscitation are suited to most newborns who need it.Some situations need special consideration.

Caesarean section

Resuscitation may be needed more often in newborns delivered by caesarean sectionbecause of the complications that made the procedure necessary and the drugs given to

the mother for analgesia and anaesthesia. It is very important to have a warm corner forthe care and resuscitation of the newborn. A radiant heater is preferable. The cord is cutbefore initiating the resuscitation.

Preterm and/or low birth weight infant

Resuscitation is also needed more often if the newborn is preterm and/orgrowth-retarded. The lower the gestational age, the more difficulties the newborn mayhave in starting breathing spontaneously. The principles of resuscitation are the same asfor term infants, but preterm newborns often take longer than term infants to startbreathing spontaneously and their breathing may be difficult, as shown by the chest andcostal indrawing. These newborns are more likely to require referral to a special care unit.


29/38


Apnoea after birth

Breathing of preterm newborns may be irregular with frequent pauses that may last 20-30seconds. Usually breathing resumes spontaneously. In rare cases a newborn stops

breathing for a longer period, or does not resume breathing at all. In such cases, beginresuscitation immediately. Resuscitation in preterm newborns is the same as in terminfants, as follows:

- clear the airway;- reassess breathing;- position the head;- ventilate with positive pressure.

Infection is often a cause of apnoea in a newborn. As soon as possible after resuscitationthe newborn must be examined for the cause of apnoea by a health care provider who is

skilled in the care of sick newborns.


30/38

A practical guide

6 SPECIAL CIRCUMSTANCES

Mouth to mouth-and-nose breathingNewborn resuscitation is always feasible, even in situations where no bag, mask or

mucus extractor are available. Every birth attendant should be trained in mouth tomouth-and-nose ventilation in case there is no equipment or the equipment fails.

The principles are the same: anticipation, preparation, timely recognition, and quick andcorrect action by opening the airway and ventilation. In summary, the newborn should bedried first, wrapped in a dry cloth, and assessed for crying/breathing. If the newborn isnot breathing, the airway is opened by positioning the head and ventilated by blowing airinto the baby's airway and the effect assessed by observing the chest rise. If there is bloodin the mouth or the amniotic fluid was meconium stained, the airway can be cleared bywiping the mouth with a dry cloth around the finger.

For ventilation, the resuscitator covers the newborn's nose and the mouth with her/hismouth and blows air at a frequency of around 40 breaths per minute. The amount of airblown into a newborn's lungs is much less than that needed for children or adults. Duringblowing the chest should be observed to see if it rises. The position of the newborn's headmust be checked and corrected frequently since it is more difficult to hold it in the correctposition during mouth to mouth-and-nose ventilation than when ventilating with the bag.Evaluation and duration of the ventilation are the same as when equipment is used.

This method requires as much training as the use of the bag and mask. Training shouldinclude practising achieving the correct ventilation pressure, the frequency and

assessment of ventilation, and keeping the head in the correct position.

Mouth to mouth-and-nose resuscitation in the newborn has some risk for the personresuscitating though this has not been quantified. There is a risk of infection for both thenewborn and the resuscitator, and the risk for the newborn of lung injury if theresuscitator blows too hard into its mouth. A piece of cloth can be put between thenewborn's mouth and the resuscitator's mouth in an emergency and probably reduces therisk of some infections, though it is not sufficient to prevent HIV transmission. There aremany commercial products - face shields - that serve as a barrier between theresuscitator's mouth and that of the newborn. They are in the form of a face mask with a

filter, or a piece of plastic with a filter that does not allow viruses to pass through. Mostare disposable and relatively expensive. They can be a useful alternative on rareoccasions.

Mouth-to-mask ventilationAlthough many health workers are trained in newborn resuscitation, it is not carried outbecause the bag and mask are expensive and there is some risk of infection for both thenewborn and the resuscitator.

A simple and inexpensive device/tool has therefore been developed and tested for itseffectiveness in a laboratoryxxxiii and in hospital.10 In small maternity clinics, testing withhealth workers and traditional birth attendants has shown that if proper training is given,it is easy to use.


31/38


The device is made up of a mask, valve and tube. The maskhas the same characteristics as the mask for the bag. Thevalve prevents the newborn re-breathing expired air andthe tube connects the mask with the resuscitator's mouth.

Figure 7 shows the device and Figure 8 shows how it isused.

The principles are the same for both the bag and mask ortube-to-mouth resuscitation. The only difference is that theresuscitator blows air via the tube and mask into thenewborn's lungs, instead of into the bag. Experience hasshown that health workers tend to blow too little ratherthan too much and too slowly (less than 30 breaths perminute). Blowing at correct ventialtin rate (30-40 perminute) and good blowing pressure can easily make them

dizzy (hyperventilation). Therefore it is important thatadditional training be given in order to know the correctamount and pressure of air. A simple tool has beendeveloped for this training.

The advantages are that this mask provides a good seal while the tube allows thenewborn's head to stay in a good position and allows the resuscitator to observe thenewborn's chest for rising.

Figure 8: Ventilation of the newborn using tube and mask device

Although the device protects the resuscitator from any infection from the newborn, itdoes not protect the newborn from infection by the resuscitator. The device that wastested did not have a filter and therefore the main concern is the risk of infection withtuberculosis.

Figure 7: Tube and mask


32/38

A practical guide

7 OPERATIONAL GUIDELINES

Implementation of resuscitation in practice

Recognition of birth asphyxia in a newborn and immediate resuscitation require theimmediate availability of a qualified person, appropriate equipment and organizedaction. The following steps are suggested for a country that wishes to strengthen newbornresuscitation. Since resuscitation is needed relatively seldom - at an incidence of 3-5%, abirth attendant who delivers 20 women a year will need to resuscitate probably once ayear - it is worth considering training first those birth attendants who deliver more than20 women a year. In practice, this means that health care institutions should introducebasic newborn resuscitation first. Basic resuscitation should also become part of thepre-service training of health care providers trained in midwifery.

National level

At national level the following activities and policies will help health care institutionsimprove resuscitation practices:

- legislation that allows every birth attendant to perform newborn resuscitation;- national recommendations and standards for newborn resuscitation describing the

minimum required practices and equipment, for different levels of care (home,health centre, hospital);

- recommendations for selection and purchase of equipment and supplies;- putting basic newborn resuscitation on the curricula of midwifery, nursing and

medical training;- development of training materials and courses for pre-service and in-service training

for different levels of care;- development of capacity for training;- licensing.

Local level

Every health care institution that provides delivery care must develop its own policiesand standards for newborn resuscitation. The manager or supervisor is responsible for

ensuring that the institution has a plan of action that includes:

- a written policy, standards, protocol and training course for newborn resuscitation;- a list of necessary equipment and supplies with instructions on cleaning and

maintenance;- a list of maternal and fetal complications that require the presence of persons

specially qualified in newborn resuscitation, agreed by all staff;- a contingency plan for multiple births and unusual situations;- instructions on how to document (record) the process and outcome of resuscitation;- a monitoring and evaluating process;- a programme for staff training (doctors, midwives, nurses, auxiliary midwives)

through initial and refresher courses.


33/38


The policy on resuscitation, the protocol and the procedures for recording and evaluationwill be observed to be better if they are developed with the participation of the staff. Localconditions and the availability of equipment must be taken into account when developingstandards of care. For instance, precise thermal protection procedures will depend on the

local climate and warming/cooling facilities, while methods of suctioning will depend onthe suction devices available. Stop points (when to stop resuscitation) need to be part ofthe policy. Resuscitation details should become a part of the patient's record.

Training

Gaining skills in newborn resuscitation cannot be left to the real-life situation andtherefore training using manikins is recommended. It is very important that training innewborn resuscitation concentrates on the essential facts, skills and attitudes, and usesappropriate teaching methods and teaching aids (dolls/manikins). Training must focuson decision-making and problem-solving skills in emergency situations, as well as on

manual skills and on counselling skills for communicating with parents. It mustemphasize the urgency of the situation and the need for coordinated activities bymembers of the health care team or, in case of a single health worker, on decision-makingskills in dividing attention between the mother and the newborn.

The appropriate level of competence should be achieved through continuing efforts tomaintain resuscitation skills by practising the technique and by completing appropriaterefresher courses. Regular training sessions help to update present staff and train newones.

After training, evaluation is needed to see if the standards/guidelines are beingimplemented in the work situation and if the health workers are doing what they havebeen trained to do. Re-certification should be institutionalized, with the optimal intervalsdetermined locally. Because newborn resuscitation is a relatively rare procedure, morefrequent updating of skills should be considered.

A generic training course with supporting training material on basic and advancednewborn resuscitation should be developed at national level. Locally, training coursesand materials should be adapted in accordance with the results of a situation analysis(training needs assessment) carried out before the training.

Monitoring and evaluation

Resuscitation can seldom be observed directly to assess the quality of care provided. Themost frequent method of assessment is demonstration using different case scenarios. Thismethod allows for observing both manual and decision-making skill. Actual clinicalpractice can be evaluated by comparing the skills demonstrated against checklistsdeveloped on the basis of local standards and protocols.

Practices should also be evaluated after a resuscitation fails. Staff discussions can provide

useful ideas for improving practices. A checklist can be helpful. If problems are found theteam should analyse present practice, compare it to standards, make recommendations,and plan and implement them.


34/38

A practical guide


35/38


8 GLOSSARY

Birth asphyxia In this paper the term is used for failure to initiate and sustain

breathing at birth. It is not used as a predictor of outcome.

Birth attendant A trained person with midwifery skills providing delivery care formother and newborn.

Birth weight The first weight of the newborn, measured to the nearest fivegrams. It is usually obtained within the first hours of birth.

Cleaning The physical removal of most microorganisms and contamination,using detergent and water.

Disinfection Treatment of objects or surfaces to remove or inactivate organismssuch as vegetative bacteria, viruses and fungi, but not spores.Disinfection can be achieved by heat, by immersion in boilingwater or by applying certain antiseptics.

Evaluation The process of collecting and analysing information at regularintervals about the effectiveness and impact of the programme.

Gasping Occasional breaths with long pauses in between, not sufficientbreathing.

Health care institution An institution where delivery care is provided by health workerswith midwifery skills (health centre, maternity unit, hospital).

Malformation Also congenital anomaly or birth defect. Any defect present atbirth, probably of developmental origin.

Low birth weight A birth weight of less than 2500 g.

Very low birth weight A birth weight of less than 1500 g.

Live birth The complete expulsion or extraction from its mother of a productof conception, irrespective of the duration of the pregnancy, which,after such separation, breathes or shows any other evidence of life.

Monitoring The ongoing process of collecting and analysing informationabout the implementation of the activity such as newbornresuscitation.

Neonatal death Death of a live-born infant during the first 28 completed days oflife. May be subdivided into early neonatal death, occurring

during the first seven days of life, and late neonatal death,occurring after the seventh day but before 28 completed days oflife.


36/38

A practical guide

Perinatal death Death of a fetus or a newborn in the perinatal period thatcommences at 22 completed weeks (154 days) of gestation (thetime when birth weight is normally 500 g) and ends seven

completed days after birth.

Policy A written statement used to guide and determine present andfuture decisions about standards of care.

Post-term 42 completed weeks or more (294 days or more) of gestation.

Pre-term Less than 37 completed weeks (less than 259 days) of gestation.

Standard of care Professionally developed detailed written statement used to guideprocedures.

Sterilization The complete destruction of all microorganisms, including spores.It can be achieved by dry heat or steam under pressure.

Stillbirth* The complete expulsion or extraction from its mother of a productof conception, of at least 22 weeks gestation or 500 grams, whichafter separation did not show any signs of life.

Term From 37 completed weeks to less than 42 completed weeks (259 to293 days) of gestation.

* For the purposes of this document the official WHO definition was modified.


37/38


9 REFERENCES

i. Palme C. "State of the art" in workshop participating countries: a report of a survey. In:Breathing and warmth at birth. Sterky G, Tafari N, Tunell R, (eds.) SAREC report

R2,1985,29-32.

ii. Kinoti SN. Asphyxia of the newborn in East, Central and Southern Africa.East African Med

J., 1993, 70:422-433.

iii. Shah PM. Birth asphyxia: a crucial issue in the prevention of developmental disabilities.

Midwifery, 1990, 6:99-107.

iv. The World Health Report 1995. Geneva, World Health Organization, 1997, p. 21.

v. Costello AM, Manandhar DS. Perinatal asphyxia in less developed countries.Arch Dis Child,1994, 71:F1-F3.

vi. Kumar R. A community-based study on birth asphyxia risk factors.IJPSM

1995, 26:53-59.

vii. Kumar R. Effect of training on the resuscitation practices of traditional birth attendants. Trans

Royal Soc Trop Med Hyg, 1994, 88:159-160.

viii. Kumar R. Training traditional birth attendants for resuscitation of newborns. Tropical Doctor,

1995, 25:29-30.

ix. Raina N, Kumar V. Management of birth asphyxia by traditional birth attendants. World

Health Forum, 1989, 10:243-246.

x. Masawe A, Kilwo C, Irani S et.al. Assessment of mouth-to-mask ventilation in resuscitation

of asphyctic newborn babies. A pilot study. Trop Med Inter Health, 1996, 1:865-873.

xi. Saugstad OD, Rootwelt T, Aalen O. Resuscitation of asphyxiated newborn infants with room

air or Oxygen: an international controlled trial: the resair 2 study. Pediatrics, 1998, 102(1):e1.

xii. Management of the sick newborn. Geneva, World Health Organization, 1996 (Document

WHO/FRH/MSM/96.12).

xiii. Tyson J, Silverman W, Reisch J. Immediate care of the newborn infant. In: Chalmers I, Enkin

M Keirse MJNC (eds.)Effective care in pregnancy and childbirth . Oxford, Oxford University

Press, 1989, 1293-1312.

xiv. Tyson JE. Immediate care of the newborn infant. In: Sinclair JC, Bracken MB (eds.)Effective

care of the newborn infant. Oxford, Oxford University Press, 1992. 21-39

xv. Palme-Kilander C, Tunell R, Chiwei Y. Pulmonary gas exchange immediately after birth in

spontaneously breathing infants.Arch Dis Child, 1993, 68:6-10.

xvi. Peliowski A, Finner N.N. Birth asphyxia in the term infant. In: Sinclair JC, Bracken MB (eds.)Effective care of the newborn infant. Oxford, Oxford University Press, 1992, 249-273.


38/38

A practical guide

xvii. Hull J, Dodd K. What is birth asphyxia?Br J Ob Gyn, 1991, 98:953-955.

xviii. Blair E. A research definition for birth asphyxia. Develop Med Child Neurol, 1993,

35:449-455.

xix. Thermal protection of the newborn: a practical guide. Geneva, World Health Organization,

1997 (Document WHO/RHT/MSM/97.2).

xx. Palme-Kilander C, Tunell R. Pulmonary gas exchange during face mask ventilation

immediately after birth.Arch Dis Child, 1993, 68:11-16.

xxi. Palme C, Nystrm B, Tunell R. An evaluation of the efficiency of face mask in the

resuscitation of newborn infants.Lancet, 1985, I (8422):207-210.

xxii. Palme-Kilander. Methods of resuscitation in low-Apgar-score newborn infants - a national

survey.Acta Paediatr, 1992, 81:739-744.

xxiii. Ramji S, Ahuja S, Thirupuram S et al. Resuscitation of asphyctic newborn infants with room

air or 100% oxygen. Pediatr Res, 1993, 34:809-812.

xxiv. Saugstad OD. Resuscitation of newborn infants: do we need new guidelines? Prenatal and

neonatal medicine, 1996, 1:26-28.

xxv. Oxygen therapy for acute respiratory infection in young children in developing countries.

Geneva, World Health Organization, 1993 (Document WHO/ARI/93.28).

xxvi. Thornberg E, Thiringer K, Odeback A et al. Birth asphyxia: incidence, clinical course and

outcome in a Swedish population.Acta Paediatr, 1995, 84:927-932.

xxvii. Whitelaw CC, Goldsmith LJ. Comparison of two techniques for determining the presence

of a pulse in an infant (letter).Academic emergency medicine, 1997, 4:153-154.

xxviii. Neonatal resuscitation. American Academy of Pediatrics, 1995.

xxix. Carrasco M, Martell M, Estol PC. Oronasopharyngeal suction at birth: effects on arterial

oxygen saturation. J Pediatr, 1997, 130:832-834.

xxx. Goldsmith JP, Ginsberg HG, McGettigan MC. Ethical decisions in the delivery room. Clinics

in Perinatol, 1996, 23:529-550.

xxxi. Congenital malformations worldwide. A report from the International Clearinghouse of Birth

Defects Monitoring System. Elsevier, 1991.

xxxii. Jain L, Ferre C, Vidyasagar D et al. Cardiopulmonary resuscitation of apparently stillborn

infants: survival and long-term outcome.J Pediatr, 1991, 118:778-782.

xxxiii. Milner AD, Stokes GM, Tunell R. Laboratory assessment of Laerdal mouth tube masks

prototype resuscitation device,Med & Biol Eng & Comput, 1992, 30: 117-119.

basic resuscitation guideline who

Documents